Download NCLEX PREPARATION PROGRAM MODULE 7

NCLEX-RN PREPARATION
PROGRAM
MENTAL HEALTH
DISORDERS
Module 6, Part 2 of 3
Major Mental Health Disorders
PERSONALITY DISORDERS (PD)
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Diagnostic criteria (Axis II, DSM-IV): “Enduring pattern
of inner experience & behavior that deviates from
expectations in 2 or more areas”:
 Cognition
 Affectivity
 Interpersonal functioning
 Impulse control
Hinders one’s ability to
 Maintain meaningful relationships
 Feel fulfilled & enjoy life
 Adjust psychosocially (cope)
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Personality Disorder Clusters
A. Odd-eccentric
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Paranoid
Schizoid
Schizotypal
B. DramaticEmotionally Erratic
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Borderline (BPD)
Antisocial (APD)
Narcissistic
Histrionic
C. Anxious-Fearful
Dependent
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Obsessive-Compulsive
Avoidant
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Personality Disorders
Cluster A: Odd-Eccentric
A profound deficit in the ability to form personal
relationships or respond to others in a meaningful way.
Appear indifferent, aloof and/or unresponsive to praise or
criticism. Typically have no close friends and prefer to be
alone. Social detachment and consequent impairment in
social & occupational functioning.
 Paranoid - pervasive distrust
 Cognitive impairment is more serious with Cluster A
personality disorders than with cluster B & C disorders
 Most peculiar & maladaptive defensive styles
 Observed in families with schizophrenia, especially
schizotypal
4
Personality Disorders
Cluster B: Dramatic and Emotional
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Present oriented and want immediate gratification
Act without evaluating consequences (impulsive)
BPD more likely to hurt self. APD more likely to
aggress outward
APD commonly involved in criminal activities and
lack remorse or guilt - emotionally retarded
Self-centered and manipulative
Splitting (the inability to integrate the positive and
negative qualities of oneself or others into a
cohesive image)
5
Personality Disorders
Cluster C: Anxious-Fearful
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Present as primarily anxious or fearful
Experience impairment as
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Restricted affect: problems expressing feelings
Non-assertiveness, avoids conflict
Unrealistic expectations of others
Rely on others for support and decision-making
Unable to function without a partner or family
member - stays in abusive relationship rather than
be alone
6
Bistro of the
Personality Disorders
(PDs)
Schizoid - Orders home delivery; ingests food through mail slot
Schizotypal - Eats soup using gardening equipment & chop sticks
Paranoid - Sits with back to the wall; spies on food prep area
Antisocial P.D. - Steals tip left by narcissist
Borderline P.D. - When informed her boyfriend plans to go duck
hunting, throws a drink at him, then uses glass to cut self
Histrionic - Does a belly dance in the center of the restaurant
Narcissist - Expects best table without a reservation
Avoidant - Tips generously for take-out service
Dependent - Vegetarian non-smoker eats veal in smoking area
to please date
7
OCPD - Aligns cutlery & dispenses etiquette tips
Personality Disorders
Interventions
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Establish therapeutic relationship
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Control
Milieu therapy
Provide experienced, consistent staff
Implement a structure with rules that are
firm & consistently enforced (limit setting
with consequences)
Protection from self-harm
Modify impulsive behavior
Incorporate behavioral strategies
8
Personality Disorders
Interventions (continued)
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Medications have a limited role:
Decrease impulsivity, mood swings,
anxiety
Teach how to get needs met without
manipulation
Maintain matter-of-fact but caring
approach; mobilize healthy aspects of
personality
9
Personality Disorders
Goals
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Less impulsive
Able to meet needs without manipulating
Increased satisfaction with quality of
relationships
Participates in close relationships
Expresses recognition of positive
behavioral change
10
A client recently released from prison for
embezzlement has a history of becoming defensive
and angry when criticized and blaming others for
personal problems. The client has expressed no
remorse or emotion about the actions that resulted
in the prison term, but instead says that the
embezzlement was justifiable because the
employer “did not treat me fairly.” The nurse
concludes these behaviors are consistent with
which of the following mental health problems?
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A. Narcissistic personality disorder
B. Histrionic personality disorder
C. Antisocial personality disorder
D. Borderline personality disorder
11
Which intervention strategy should the
nurse routinely include in the nursing care
plan for a client with antisocial personality
disorder?
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A. Establish clear and enforceable limits.
B. Vary unit rules based on client demands.
C. Vary unit rules based on staff needs.
D. Let the client have a voice in when unit
rules should apply.
12
Anxiety Disorders
Description
An unrealistic fear in which the cause may or may not be
identified.
 Symptoms: Anxiety and avoidance behavior
 Familial predisposition
 Results from
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Exposure to traumatic and stressful life events
Observing others experiencing trauma or behaving fearfully
Vicariously through watching movies and TV
Physical symptoms occur
13
Anxiety Disorders
Central Features
 Pervasive anxiety
 Feelings of inadequacy
 Tendency to avoid
 Self-defeating behavior blocks growth
 Can stimulate action to alter stressful situation
 Most symptoms of the body involved
 See physician vs. psychiatrist for treatment
14
Anxiety Disorders
Assessment
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Restlessness and inability to relax
Episodes of trembling and shakiness
Chronic muscular tension
Dizziness
Inability to concentrate
Fatigue and sleep problems
Inability to recognize connection between
anxiety and physical symptoms
Focused on the physical discomfort
15
Anxiety Disorders
Generalized Anxiety Disorder
GAD
 Chronic excessive worry about a number of events
or activities for at least 6 months.
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History of uncontrollable & unpredictable life stress prone to Generalized Anxiety Disorder (GAD)
Unrealistic/excessive
Motor tension, autonomic hyperactivity, apprehensive
expectations, vigilance & scanning
Experiences at least 3 of the following:
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Restlessness, fatigue, difficulty concentrating or mind
going blank, irritability, muscle tension, sleep
disturbance
16
Anxiety Disorders
Panic Disorders
Panic Disorders
 Panic Disorder - discrete episode of intense fear
Sense of impending doom, helplessness, or being trapped
Peaks within 10 minutes
Occurs unexpectedly and on an intermittent basis
Concern about additional attacks
 Panic Disorder with agoraphobia
Avoidance of places or situations in which escape is
difficult or help not available in the event of a panic attack
(i.e., outside the home alone, being in a crowd…)
17
Anxiety Disorders
Post-traumatic Stress Disorder
PTSD
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Development of physiologic/behavioral symptoms
following a psychologically traumatic event
A traumatic event is unavoidable (terrorist attacks, war,
rape, crime events, disasters, fires, childhood sexual
abuse, kidnapping, hostages)
Before exposure did not have psychological problems
Symptoms include: re-experiencing the trauma, avoiding
reminders of the trauma, numbing of affect
18
Anxiety Disorders
Phobic Disorders
Phobic Disorders
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Social phobia 
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Fear of scrutiny (evaluated or judged) by others
Fearful of doing something or acting in a way that will
be humiliating or embarrassing
Specific Phobia
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Persistent irrational fears of specific objects or
situations
i.e., Animals (zoophobia), fear of closed places
(claustrophobia), & fear of heights (acrophobia)
What are some other common phobias?
19
Anxiety Disorders
Obsessive-Compulsive Disorder
OCD
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Obsessions
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Compulsions
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Unwanted, persistent, & intrusive thoughts, impulses
or images that cause anxiety or distress
Irrational impulse to act
Behaviors or mental rituals performed to
neutralize/prevent the distressing thoughts or images
Thoughts about dirt, contamination and danger most
common obsessions; cleaning & checking for danger
most common ritual
20
Anxiety Disorder Medications
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Buspirone (Buspar)
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Minimal CNS depressant actions
Does not enhance effects of alcohol, barbiturates & other
general CNS depressants. Takes several weeks to
establish effectiveness.
Benzodiazpam
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Adverse effects:
 CNS Depression
 Amnesia
 Respiratory Depression
 Dependence and abuse
 E.g. Valium, Librium, Xanax
21
Anxiety Disorder Medications
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Beta-adrenergic blocking agents such as propranolol
(Inderal) can relieve symptoms caused by autonomic
hyperactivity
Selective Serotonin Reuptake Inhibitors (Paxil,
Proxac…), Tricyclic Antidepressants (Imipramine Tofranil)
Barbituates
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CNS depression
High abuse potential
Powerful respiratory depressants with strong potential for
fatal overdose
22
Anxiety Disorder Assessment
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Take steps to lower anxiety level
Encourage trust/calm approach
Assess current feelings
What happened immediately prior to onset?
Client’s perspective of situation
Thought processes
Affect, expression, nonverbal behaviors
Communication ability, thought blocking
23
Anxiety Disorder Interventions
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Establish trusting relationship
Nurses’ self-awareness
Recognition of anxiety
Insight into anxiety
Modifying environment
Encouraging activity
Promote relaxation response
Learn new ways to cope with stress
Medication
Goal: Client will demonstrate adaptive ways of coping
with stress
24
A client who is hospitalized for panic
disorder is experiencing increased anxiety.
The client exhibits selective inattention and
tells the nurse, “I’m anxious now.” The
nurse determines that the degree of the
client’s anxiety is:
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A. Mild
B. Moderate
C. Severe
D. Panic
25
During an assessment interview, the client tells the
nurse, “I can’t stop worrying about my makeup. I
can’t go anywhere or do anything unless my
makeup is fresh and perfect. I wash my face and
put on fresh makeup at least once and sometimes
twice an hour.” The nurse’s priority should be to
adjust the client’s plan of care so the client will be:
A. Required to spend daytime hours out of own room
B. Given advance notice of approaching time for all group
therapy sessions
C. Asked to keep a diary of feelings experienced if unable to
groom self at will
D. Allowed to use own cosmetics and grooming products
26
A client asks why a beta blocker (Inderal)
medication has been prescribed for anxiety.
When answering this question, the nurse should
explain that this medication class is effective for
treatment of which symptoms associated with
anxiety?
A. Cognitive dissonance and confusion
B. Depression and suicidal ideations
C. Insomnia and nightmares
D. Palpitations and rapid heart beat
27
Somatoform Disorders
Focus: Physical symptoms with
absence of a pathophysiological problem
1.
2.
3.
4.
5.
Somatization Disorder
Hypochondriasis
Conversion Disorder
Pain Disorder
Body Dysmorphic Disorder
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Somatoform Disorders
Somatization Disorder
 Involvement of multiorgan system symptoms: pain, GI,
sexual, pseudoneurological
 Lack physical signs or structural abnormalities
 Different than hypochondriasis in that preoccupation
occurs only during episode
Hypochondriasis
 Preoccupation with fear of having serious illness and
hypersensitive to body functions
 Becomes central feature of self-image, topic of social
interaction and response to life stresses
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Somatoform Disorders
Conversion Disorder
 A symptom or deficit that affects motor or sensory
functioning
 Inappropriately unconcerned about symptoms
 Symptoms remit within 2 wks, recurrence common
 Common symptoms are blindness, deafness, paralysis
and the inability to talk
Pain Disorder
 Preoccupation with pain after confirmation of absence of
pathophysiologic causes
30
Somatoform Disorders
Body Dysmorphic Disorder
Preoccupation with an imagined/exaggerated
defect in physical appearance
 Crooked lip, bumpy nose, falling face
Somatoform Interventions: Client education
 Medications, Rx, lifestyle changes, ways to
cope with anxiety & stress, relaxation training,
physical activity
Goal: Client will express feelings verbally rather
than through physical symptoms
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31
An older client with chronic low back pain
receives cooking and cleaning help from her
extended family. The mental health nurse
anticipates that this client benefits from which
of the following in this situation?
A. Primary gain
B. Secondary gain
C. Attention-seeking
D. Malingering
32
What would the nurse expect a client who
has a somatization disorder to reveal in the
nursing history?
A. Abrupt onset of physical symptoms at menopause
B. Episodes of personality dissociation
C. Ignoring physical symptoms until role performance
was altered
D. Numerous physical symptoms in many organ areas
33
A client treated for hypochondriasis would
demonstrate understanding of the disorder
by which statement to the nurse?
A. “I realize that tests and lab results cannot
pick up on the seriousness of my illness.”
B. “Once my family realizes how severely ill I
am, they will be more understanding.”
C. “I know that I don’t have a serious illness,
even though I still worry about my
symptoms.”
D. “I realize that exposure to toxins can cause
significant organ damage.”
34
Dissociative Disorders
35
Dissociative Disorders
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Avoids stress by dissociating self from
core personality, characterized by
sudden or gradual disruption in identity,
memory or consciousness
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Dissociative Amnesia
Dissociative Fugue
Dissociative Identity Disorder
Depersonalization Disorder
36
Dissociative Disorders
Dissociative Amnesia
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Inability to recall important personal information
Too extensive to be explained by ordinary
forgetfulness
Dissociative Fugue
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Sudden, unexpected travel away from home or work
Inability to recall one’s past
Confusion about personal identity (ID) or assumption
of a new ID
37
Dissociative Disorders
Dissociative Identity Disorder
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Formally “Multiple Personality Disorder”
Presence of 2 or more distinct identities that recurrently
take over behavior
Inability to recall important personal info
Identity fragmentation
Often a history of physical &/or sexual abuse
Depersonalization Disorder
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Recurrent feeling of being detached from one’s mental
processes or body
Intact reality testing
38
Dissociative Disorders: Interventions
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Development of insight
Identify stressors
Clarify beliefs in relationship to feelings and
behaviors
Explore use of coping resources
Decrease anxiety through stress management
Goal
 Obtain the maximum level of self-actualization to
realize potential
39
The spouse of a client who is experiencing a
fugue state asks the nurse if the spouse will be
able to remember what happened during the
time of fugue. What is the nurse’s best
response?
A. “Your spouse will probably have no memory for
events during the fugue.”
B. “Your spouse will be able to tell you – if you can
gently encourage talking.”
C. “It is not possible to predict whether your spouse
will remember the fugue state.”
D. “Avoid mentioning it, or your spouse may start
alternating old and new identities.”
40
Mood Disorders: Major
Depressive Disorder and
Bipolar Disorders
Mood Disorder
A mood disorder is characterized by:
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Depressed mood or cycles of depressed and
elated mood
Feelings of hopelessness and helplessness
Decrease in interest or pleasure in usual activities
41
Mood Disorders: Major
Depressive Disorders
Depression Models of Causation
 Biological factors
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Genetic factors
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Serotonin, norepinephrine, and acetylcholine deficiencies
Effect of light on mood
Familial predisposition
Situational, physiological, and psychosocial
stressors
Learned hopelessness and helplessness and a
negative self-view
42
Mood Disorders
Depression: Signs and Symptoms
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Cognitive: Difficulty concentrating, focusing, and problem
solving; ambivalence, confusion, sleep disturbances
Loss of interest or motivation, anhedonia
Decrease in personal hygiene
Anxiety, worthlessness, helplessness, hopelessness
Psychomotor retardation/agitation
Vegetative signs: Hypersomnia, slowed bowel function
Risk of harm to self or other: Suicidal ideation or
thoughts, self-destructive acts, violence, overt hostility
often connected with suicidal thoughts
43
Mood Disorders
Depression: Psychotrophics
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Selective Serotonin Reuptake Inhibitors
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Rapid onset, fewer side effects, higher rate of
compliance, lower overdose harm
Citalopram (Celexa)
Paroxetine (Paxil)
Fluoxetine (Prozac)
Sertraline (Zoloft)
Escitalopram (Lexapro)
Fluvaxamine (Luvox)
44
Mood Disorders
SSRI Considerations
Selective Serotonin Reuptake Inhibitors
(SSRIs):
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Physical assessment: renal, liver function,
seizures
Agitation vs. vegetative symptoms
Level of anxiety
Ease of compliance
Risk for suicide by overdose
45
Mood Disorders
Serotonin Syndrome
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Cause: Excess Serotonin at receptor sites
Onset 3-9 days
Symptoms: fever, confusion, restlessness, agitation,
hyper-reflexia, diaphoresis, shivering, diarrhea, fever,
poor coordination
Triggered by high doses, concurrent MAOI, lithium or
Trazadone administration
Interventions: Hold meds, notify MD, give P.O. fluids,
supervise and support patient, antipyretics, cooling blanket
Resolves without specific treatment over 24 hours
46
Mood Disorders
Depression: Psychotrophics
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Novel antidepressants:
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Bupropion (Wellbutrin)
Nefazadone (Serzone)
Trazadone (Desyrel)
Venlafaxine (Effexor)
Mirtazipine (Remeron)
Duloxetine (Cymbalta)
47
Mood Disorders
Depression: Psychotrophics
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Tricyclic antidepressants
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Amitriptyline (Elavil)
Clomipramine (Anafranil)
Desipramine (Norpramin)
Doxepin (Sinequan)
Imipramine (Tofranil)
Nortriptyline (Pamelor)
Trimipramine (Surmontil)
48
Mood Disorders
Depression: Psychotrophics
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Monoamine Oxidase Inhibitors
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Tranylcypromine (Parnate)
Phenelzine (Nardil)
Isocarboxazid (Marplan)
Tyramine-rich foods to avoid: aged cheese,
sausage, beer on tap, sauerkraut, soy sauce,red
wine
OTC cold remedies, tricyclic antidepressants,
narcotics, antihypertensives, stimulants
49
Mood Disorders
Nursing Interventions for Depression:
Maintain safety
 Question negative beliefs
 Encourage activities to increase self-esteem
 Encourage ADLs
 Encourage physical activity
 Medication teaching
 Milieu, group and/or individual therapy
Goals
 No self-harm
 Resolution of negative self-image and situational insight
 Restoration of normal physical functioning
50
 Medication compliance, relapse prevention
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The nurse has explained to a client the biologic
theories of depression. The nurse concludes
that the teaching has been effective if the client
says, “I now know that my depression may be
caused from:
A. Excessive serotonin activity in the central
nervous system (CNS).”
B. Insufficient serotonin activity in the CNS.”
C. Excessive norepinephrine in the CNS.”
D. Insufficient acetylcholine activity in the CNS.”
E. A genetic mutation on chromosome 6.”
51
A 63-year-old male client expresses feelings of
hopelessness and helplessness about his
spouse’s illness and anticipated death.
On which of the following issues should the
nurse initially assist the client to focus?
A. The nature of the spouse’s present illness
B. The client’s response to past losses
C. The dying spouse’s feelings about
impending loss and death
D. The client’s relationship with the spouse
52
Mood Disorders: Bipolar Disorder
Bipolar Disorder
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A mood disorder, formerly known as manic
depression, characterized by recurrent and
typically alternating episodes of depression and
mania.
Either phase may be predominant at any given
time or elements of both phases may be present
simultaneously.
53
Mood Disorders
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Bipolar Disorder
Biological Factors
Possible excess of norepinephrine, serotonin
and dopamine
Increased intracellular sodium and calcium
Neurotransmitters supersensitive to
transmission of impulses
Defective feedback mechanism in limbic
system
54
Mood Disorders
Bipolar Disorder: Signs and Symptoms of Mania
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Impulsivity: Spending money, giving away money or
possessions, hypersexual behavior
Racing thoughts, hyper-social
Increased activity, grandiose view of self and abilities
Mood elation, progressively more hostile
Speech loud, jovial, pressured
Poor judgment
Reduced sleep
Impairment in social and occupational functioning
55
Mood Disorders
Bipolar Disorder: Psychotrophics
Lithium Carbonate (Carbolith, Eskalith..)
Anticonvulsants
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Valproate, (Depakote)
Carbamazepine (Tegretol)
Gabapentin (Neurontin)
Topiramate (Topamax)
Lamotrogene (Lamictal)
Benzodiazapines
Antipsychotics such as Olanzapine (Zyprexa)
and Arpiprazole (Abilify)
Electroconvulsive therapy
56
Mood Disorders
Bipolar Disorder: Medical Management
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Lithium can have potentially harmful effects on the
kidney, thyroid gland, heart and developing fetus
Pre-lithium treatment lab tests
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Thyroid Function Tests (e.g. TSH),
CBC (benign elevation of WBCs),
BUN, serum creatinine, electrolytes
Urinalysis,
ECG,, pregnancy test
During Lithium treatment: TSH, BUN, serum creatinine,
ECGs every 6 to 12 months
57
Mood Disorders
Bipolar Disorder: Medical Management
Lithium
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Monitor serum levels or lithium (0.5-1.0 mEg/L) to prevent
toxicity and confirm compliance. Report sub-therapeutic or
toxic levels to prescribing practitioner
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Encourage adequate hydration and adequate dietary salt
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Therapeutic improvement takes 1-3 weeks
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Tremors and a metallic taste are side effects
Anticonvulsants as Mood Stabilizers
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Monitor serum levels every 2-4 months (liver function tests,
complete blood count, electrolytes, ECG, pregnancy test
every 6-12 months)
58
Mood Disorders
Bipolar Disorder Nursing Interventions and Goals
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Maintain physical safety (self harm, assault, impulse control,
exhaustion)
Decrease sensory stimulation
Establish normal sleep/rest cycle
Establish adequate food/fluid intake
Limit escalation of behavior
Provide reality orientation
Psychoeducation: Disease process, target symptoms, self
monitoring, alternative coping behaviors, self-care measures,
medication management, medication compliance, laboratory
monitoring, side effect management, community resources,
relapse prevention, reinforce abstinence from drugs and alcohol
59
The client has bipolar I disorder. Lithium carbonate
(Lithium) 300 mg four times a daily has been
prescribed. After 3 days of lithium therapy, the
client says, “What’s wrong? My hands are shaking
a little.” The best response of the nurse is:
A. “Minor hand trembling often happens for a few days after
Lithium is started. It usually decreases in 1 to 2 weeks.”
B. “There’s no reason to worry about that. We won’t, unless it
lasts longer than a couple of weeks.”
C. “Just in case your blood level is too high, I am not going to
give you your next dose of Lithium.”
D. “I wouldn’t worry about it if I were you. It’s a small tremor
that doesn’t interfere with your functioning.”
60
Thought Disorders
Schizophrenia

Involves disturbances in:

Reality, thought processes, perception, affect,
social and occupational functioning

1.5% of the population
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75% of cases diagnosed between ages 17 and 25

Causation: Heredity/genetic transmission,
psychodynamics, stress, drug abuse, excessive
dopamine. CT and MRI studies show decreased
brain volume, enlarged ventricles, deeper fissures,
and/or underdevelopment of brain tissue
61
Thought Disorders
Schizophrenia: Types
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Catatonic
Disorganized
Paranoid
Undifferentiated
Residual
62
Thought Disorders
Schizophrenia: Types

Catatonic Type
Catatonic stupor, evidenced by extreme
psychomotor retardation and posturing, and
catatonic excitement, extreme psychomotor
agitation with purposeless movements that
may harm self or others
63
Thought Disorders
Schizophrenia: Types
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
Disorganized Type
Flat or inappropriate affect (such as silliness or
giggling), bizarre behavior and social impairment
Paranoid Type
Paranoid delusions in which the individual falsely
believes that others are out to harm him/her. The
individual may be hostile, argumentative and
aggressive
64
Thought Disorders
Schizophrenia: Types


Undifferentiated Type
Bizarre behavior that does not meet the criteria
of other types of schizophrenia. Delusions and
hallucinations are prominent
Residual Type
Individual who has had one major episode of
schizophrenia with prominent psychotic
symptoms and who has lingering symptoms
65
Thought Disorders
Schizophrenia: Diagnostic Criteria




Delusions, hallucinations, disorganized speech
and/or behavior
Social and/or occupational impairment
Symptoms for at least 6 months
Not attributable to another disorder
66
Thought Disorders
Schizophrenia:
Positive and Negative Symptoms


Positive: delusions, hallucinations, bizarre
behavior, agitation, pressured speech, suicidal
ideation
Negative: Flat affect, poor eye contact,
withdrawal, anhedonia, poverty of speech,
apathy, inattention, lack of motivation
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Thought Disorders
Schizophrenia:
Positive Signs and Symptoms
 Hallucinations: Auditory, visual, olfactory, gustatory, tactile
 Illusions: False interpretations of external sensory stimuli
and inappropriate responses to the perception.
 Alterations in thinking
Delusions - Fixed false beliefs (grandiose, persecutory,
somatic…)
Thought broadcasting, insertion
 Ideas of reference
 Flight of ideas
 Thought/language disruption
68
Thought Disorders
Schizophrenia:
Co-Morbid Conditions and Effects






Anxiety, depression, suicidal ideation
Substance abuse
Impaired occupational and interpersonal
relationships
Decreased self-care
Poor social functioning
Lowered quality of life
69
Thought Disorders
Schizophrenia: Psychotrophics

Antipsychotic medications decrease the
intensity and frequency of psychotic symptoms.

Anti-Parkinsonian medications are used to
counteract the extrapyramidal symptoms (EPS)
associated with antipsychotic medications.
70
Thought Disorders
Schizophrenia: Psychotrophics
 Phenothiazines
Chlorpormazine (Thorazine), trifluoperazine
(Stelazine), Thioridazine (Mellaril)…

Atypical
Clozapine (Clozaril), Olanzapine (Zyprexa),
Risperidone (Risperdal), Ziprasidone (Geodon),
Arpiprazole (Abilify), Quetiapine Fumarate
(Seroquel)
71
Thought Disorders
Schizophrenia: Psychotrophic Side Effects

Acute





Dystonic reaction
Ocular crisis
Agranulocytosis
Neuroleptic malignant syndrome
Chronic




Tardive dyskinesia
Pseudoparkinsonism
Photo sensitivity
Weight gain
72
Thought Disorders
Schizophrenia:
Psychotrophic Side Effects




Sudden onset muscular rigidity, fever, elevated
CPK
Escalates over 24-48 hours
Late: hypertension, confusion-coma, gross
diaphoresis, dysphagia, tachycardia
High potency neuroleptics, dosage, mood
disorders, concurrent lithium and polypharmacy
73
Thought Disorders
Schizophrenia: Factors Supporting Compliance
 Perception of illness
 Risk for relapse
 Knowledge/involvement with treatment plan
 Optimism regarding positive effects
 Awareness of unpleasant effects when meds stopped
 Psychoeducation regarding psychotropic medications’
action, purpose, intended effects, management of
side effects, toxic or dangerous effects and treatment
for side effects
74
Thought Disorders
Schizophrenia: Factors Inhibiting Compliance
 Delusions about medications
 Return of enjoyable symptoms
 Lack of social support regarding taking meds
 Side effects distressing
 Requires multiple changes in habits
 Multiple medications
75
Thought Disorders
Schizophrenia: Interventions
 Establish & maintain safe environment
 Establish trust
 Manage delusions
 Focus on feelings versus delusions
 Engage in reality testing
 Validate functional behaviors
 Anxiety management
 Stress reduction strategies
76
The major advantage of the newer atypical
antipsychotics over older phenothiazines
and high potency antipsychotic medication
is:
A. Less chance for agranulocytosis
B. Availability as a long-lasting injection
C. Absence of EPS
D. Resolution of positive and negative symptoms

77
A patient with schizophrenia tells you that voices
in his head are telling him he is in danger, and
that he must stay in his room. He asks you, "Do
you hear them?" Your best therapeutic response
would be:
A. “I know these voices are very real to you, but I don't
hear them.”
B. “You need to get out of your room and get your mind
occupied so you don't hear the voices."
C. “Don't worry. You're safe in the hospital. I won't let
anything happen to you.”
D. “The voices are coming from your imagination.”
78
Substance Abuse/Dependence

Incidence




Defense Mechanisms


Alcohol dependence/abuse 14%
Drug dependence 3%
Co-morbidity common
Rationalization, projection, denial
CNS depressants

Alcohol, benzodiazapines, barbituates
79
Substance Abuse
 Maladaptive, recurring use of substance
accompanied by repeated detrimental
effects of drug
 Present for one year or more
 Episodic binges
 Can occur without dependency
 Encounters with law, school suspension,
family/marital problems
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Substance Intoxication
Maladaptive, reversible pattern of behavior




Perceptual disturbances
Sleep—wake cycle changes
Disturbs attention, concentration, thinking,
judgment, psychomotor activity
Interferes with relationships
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Substance Dependence






Craving – strong inner drive to use substance unsuccessful efforts to control use
Tolerance – decreased effectiveness of drug over
time with need for increased doses of substance to
achieve same effect
Withdrawal – unpleasant, maladaptive changes in
behavior as blood/tissue concentrations of substance
decline after prolonged heavy use
Much time used in obtaining substance
Activities given up in lieu of substance use
Continued use in spite of negative problems from
usage
82
Substance Dependence





Larger amounts over longer time period than
intended
Persistent desire/unsuccessful efforts to
control use
Much time used in obtaining substance
Activities given up in lieu of substance use
Continued use in spite of negative problems
from usage
83
Substance Dependence
PHASES
 Phase 1
 Mood swings, altered emotional state
 Phase 2
 Hangover effects, guilt about behavior
 Phase 3
 Dependent lifestyle, control over substance is lost
 Phase 4
 Dependency, addiction, blackouts, paranoia,
helplessness
84
Substance Abuse/Dependence
Possible long-term effects of chronic alcohol abuse
 Gastritis
 Esophagitis
 Acute or chronic pancreatitis
 Cirrhosis
 Cardiac problems
 Neurological problems
 Wernicke-Korsakoff’s syndrome
 Osteoporosis and myopathy
85
Alcohol Withdrawal
Accompanied by physiologic/cognitive symptoms
from reduction in prolonged substance use
 Early Signs
 Develop within few hours after cessation/peak at
24-48 hours
 Anxiety, anorexia, insomnia, tremors, hyperactivity,
irritability, “shaking inside,” hallucinations, illusions,
nausea/vomiting, Increased Temp, pulse, and BP
 Delirium Tremens (DTs)


Peak in 48-72 hours after cessation of drinking –
last 2-3 days
20% fatality rate
86
Nursing Interventions:
Alcohol Dependence
 Medication – sedation
 High protein, high vitamin
diet (B/C)
 Replace fluid/ electrolytes
(I/O)
•
•
Diuresis with blood alcohol
level increase
Fluid retention may occur
(overhydration)
 MgSO4 to increase
body’s response to
thiamine/raise seizure
threshold
 VS q hour x 12 h, then
q4h
•
Pulse good indicator
of progress through
withdrawal
87
Vitamin B1 Deficiency



Vitamin B1 (Thiamine) and niacin deficiency
Encephalopathy and psychosis primarily in
alcoholics caused by thiamine deficiency, due to
poor dietary intake and malabsorption (WernickeKorsakoff Syndrome)
Permanent progressive cognitive loss
88
Substance Dependence: Alcohol

Maintaining abstinence



Antidepressents - SSRIs and Buspirone (BuSpar)
Naltrexone (ReVia), Nalmefene (Revex) -opioid
antagonists that help with alcohol dependence reduces cravings and increases abstinence
Disulfiram (Antabuse) - Treat alcoholism. Inhibits
aldehyde dehydrogenase, if alcohol ingested, causes
facial flushing, tachycardia, decreased BP, nausea,
vomiting, SOB, seating dizziness and confusion
89
Substance Dependence: Alcohol

Relapse prevention




Accept as a chronic disease
Self-help groups, AA
Stress management
Family support
90
Substance Abuse/Dependence

Narcotic opiates commonly abused


Heroin, Demerol, Dilaudid, Oxycontin
Treatment





Recognition of drug seeking
Manage intoxication/overdose
Opioid withdrawal: Naltrexone (ReVia),
Buprenophine (Buprenex), Dolophine (Methadone)
Self-help groups, Narcotics Anonymous (NA)
Relapse prevention
91
Substance Abuse/Dependence
Types of Drugs Frequently Abused









Barbiturates, antianxiety drugs, hypnotics
Opioids (narcotics): heroin, morphine, meperidine, methadone,
hydromorphone
Amphetamines: amphetamine, dextroamphetamine,
methamphetamine (speed), some appetite suppressants
Cocaine, hydrochloride cocaine (crack)
Phencyclidine (PCP)
Hallucinogens: LSD, mescaline
Cannabis: marijuana, hashish, THC
Assessment findings and nursing interventions for overdose
vary with particular drug
Polydrug abusers: Synergistic effect and additive effect
92
Substance Abuse/Dependence
Reasons nurses are at high risk for substance use.
 Nurses see medication as solutions to problems
 Access to drugs at work
 Access to physicians who prescribe drugs
 Compassion fatigue: Pressure and emotional pain felt
at work
 Anger and frustration nurses feel at work
 Emotions felt at work respond to drugs– short term
93
Substance Abuse/Dependence
Signs of substance abuse in nurses






Change in nurse’s behavior
Mood changes, irritability, isolation
Change in work performance
Multiple medication errors, missed deadlines, poor
judgment, absenteeism
Signs of drug use or withdrawal
Red eyes, ataxia, anxiety, use of breath mints and
perfume, slurred speech
94
Substance Abuse/Dependence
Action plan if you suspect a peer
Report the peer suspected of drug abuse to
a manager or supervisor to:
 Protect the clients from harm
 Protect the peer from harming clients or self
 Get diagnosis and treatment for impaired peers
95
A client says, “I have a very small drink every
morning to calm my nerves and stop my hands
from trembling.” The nurse concludes that this
client is describing which of the following?
A. An anxiety disorder
B. Tolerance
C. Withdrawal
D. Alcohol abuse
96
A client asks the nurse to provide information
about the detoxification process and withdrawal
from a benzodiazepine. The nurse should
inform the client that the process will involve
which of the following?
A. Rapid reduction in amount and frequency of the
drug normally used
B. Abrupt discontinuation of the drug commonly
used
C. Gradual downward reduction in dosage of the
drug commonly used
D. Planned, progressive addition of an antipsychotic drug
97
When the nurse is caring for a client
experiencing delirium tremens, what is the
most important nursing intervention?
A. Present psycho-education on the dangers of
drug and alcohol use.
B. Encourage the client to develop a relapse
prevention plan.
C. Administer anti-craving medications.
D. Provide withdrawal care based on unit
protocol.
98
Photo Acknowledgement:
All unmarked photos and clip art
contained in this module
were obtained from the
2003 Microsoft Office Clip Art
Gallery.
99